Job description

Service Definition and Required Components

An Assertive Community Treatment (ACT) team consists of a community-based group of medical, behavioral health, and rehabilitation professionals who use a team approach to work together to meet the needs of beneficiaries with severe and persistent mental illness.
Individuals who are appropriate for ACT do not benefit from receiving services across multiple, disconnected providers, and may become at greater risk of hospitalization, homelessness, substance use, victimization, and incarceration. ACT teams provide person-centered services addressing a breadth of beneficiary’s needs, helping him or her achieve their personal goals.
Thus, a fundamental charge of ACT is to be the first line (and sole provider) of all the services that ACT beneficiaries need. Being the single point of responsibility necessitates a higher frequency and intensity of community-based contacts, and a very low beneficiary-to-staff ratio. Services are flexible; teams offer varying levels of care across all beneficiaries, and appropriately adjust service levels given an individual beneficiary’s changing needs across time.
For example, a beneficiary advancing in recovery and preparing to transfer off of the team may be seen by the team less than once per week as part of his or her transition plan. Another may need to be seen more than once a day for several months to help improve his or her stability following a recent hospital discharge, medication change, or move to
an independent living setting.
ACT teams assist beneficiaries in advancing toward personal goals with a focus on enhancing community integration and regaining valued roles (e.g., worker, daughter, resident, spouse, tenant, friend). Because ACT teams often work with beneficiaries who may passively or actively resist services, ACT teams are expected to thoughtfully carry out planned assertive engagement techniques which largely consist of rapport-building strategies, facilitating meeting basic needs, and motivational interviewing techniques.
These techniques are used to identify and focus on the beneficiary’s life goals and what he or she is motivated to change. Likewise, it is the team’s responsibility to monitor the beneficiary’s mental status in a respectful manner that is congruent with the beneficiary’s level of need and functioning.
The ACT team delivers all services according to a recovery-based philosophy of care, where the team promotes self-determination, respects the beneficiary as expert in his or her own right, and engages peers in the process of promoting hope that the beneficiary can recover from mental illness and regain meaningful roles and relationships in the community.

Service Type and Program Requirements
A fundamental feature of ACT is that services are taken to the beneficiary in his or her natural environment, rather than having the beneficiary come into an office or clinic setting to receives.

• ACT teams shall provide the majority of services to beneficiaries in the community. On average, 75% of face-to-face contacts shall be provided in the community.
• Hours of Operation:

ACT Teams are available to beneficiaries 24 hours a day, 7 days a week, 365 a year. ACT Teams should have an office open 8 hours per day, Monday through Friday, for walk-ins and calls.

• Delivery of Planned Services: Typically, only one to three team members may be needed to cover the extended afternoon and early evening hours. Team members shall flex their hours appropriate to each beneficiary’s needs at that time.
• Services are expected to be provided over the weekend and holiday, including medication monitoring, rehabilitation services, and all other applicable ACT Team services.
• Crisis Response: ACT team members shall provide “first responder” crisis response 24/7/365 to beneficiaries experiencing a crisis.
• Daily Team Meetings: The daily team meeting is the central hub of communication for ACT team staff, sharing recent assessment information and planning for the day’s activities. Attendance by all staff members is mandatory.

Staff Qualifications and Role:
ACT Team services shall be provided by a team of individuals who have strong clinical skills, professional qualifications, experience, and competency to provide a full breadth of biopsychosocial rehabilitation services. While all staff should have some level of competency across disciplines, areas of staff expertise and specialization should be emphasized to fully benefit ACT service beneficiaries. Team members strive to offer evidence-based practices, which are clinical and rehabilitation services that have been demonstrated to be effective for adults with severe and persistent mental illness. Teams must have staff that is designated to provide housing/tenancy supports to individuals living independently in the community.

The full-time Team Leader is responsible for:
A. overseeing the administrative operations of the team.
B. providing clinical oversight of services in conjunction with the Psychiatric Care Provider; as well as clinical supervision.
C. supervising team members to assure the delivery of best and ethical practices.
D. directly providing services to ACT service beneficiaries, where a therapeutic relationship is developed between ACT service beneficiaries and the Team Leader.

Example roles include:
1. assuming an active role in screening referrals and assessing beneficiaries at intake.
2. acting as a lead clinician, therefore working closely with a select group of service beneficiaries who can benefit from the Team Leader’s clinical expertise.
3. modeling behaviors through service provision for the purpose of clinical supervision.
4. participating in person-centered planning meetings; and working with beneficiary’s natural supports.

**The Team Leader is exclusively dedicated to the ACT team, with no responsibilities to other roles outside of the ACT team. Only one Qualified Professional shall assume the role as Team Leader. Qualifications are set forth in Table 2 and Division of Medical Assistance Clinical Coverage Policy 8C; the Team Leader shall meet a Qualified Professional status according to 10A NCAC27G .0104.

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